Predictive factors for recurrent acute appendicitis after conservative treatment.

INTRODUCTION: Conservative treatment of acute appendicitis is gaining popularity, and identifying patients with a higher risk of recurrence is becoming increasingly important. Previous studies have suggested that older age, male sex, diabetes, appendicolith and abscess formation may be contributing factors, however, results from the adult population are inconsistent. AIM: This study aims to identify predictive factors for recurrent appendicitis after conservative treatment. METHODS: This retrospective study included patients with conservatively treated acute appendicitis at Skåne University Hospital, Sweden during 2012-2019. Information on patient demographics at index admission and follow-up data were retrieved from medical charts and radiologic images. Uni -and multivariable logistic regression analysis were performed using Stata Statistical Software. RESULTS: In total, 379 patients with conservatively treated acute appendicitis were identified, of which 78 (20.6%) had recurrence. All patients were followed-up for a minimum of 41 months after the first diagnosis of acute appendicitis unless appendectomy after successful conservative treatment or death occurred during follow-up. The median time to recurrence was 6.5 (1-17.8) months. After multivariable logistic regression analysis, external appendix diameter >10 mm [OR 2.4 (CI 1.37-4.21), p = .002] and intra-abdominal abscess [OR 2.05 (CI 1.18-3.56), p = .011] on computed tomography were significant independent risk factors for recurrent appendicitis. Appendicolith was not associated with an increased risk of recurrence. CONCLUSION: This study suggests abscess formation and appendix distension of >10 mm to be potential risk factors for recurrent acute appendicitis after initial successful conservative treatment.

Diverticulosis and risk of diverticulitis in 10 years; a Swedish retrospective observational study.

BACKGROUND: Diverticulosis is a common condition and is thought to be increasing in the Western population. Several studies have attempted to estimate the prevalence of diverticulosis and it's inflamed state, diverticulitis, with results varying depending on study population and methodology, The aim of this study was to investigate the prevalence of diverticulosis in patients undergoing colonoscopy at a Swedish academic referral centre and to study the incidence of diverticulitis in a 10-year follow-up. METHODS: All patients who had undergone colonoscopy at the Endoscopy unit, Skåne University Hospital, Sweden, during 01 January 2010 through 31 December 2011 were identified. The colonoscopy referrals, colonoscopy reports, and medical records until 14 June 2022 were reviewed. RESULTS: In all, 2648 patients were included in the study, whereof 910 patients had reported diverticulosis (34.4%). During the 10-year follow-up, the overall incidence of computed tomography verified diverticulitis was 4.4%, and 0.6% for patients with and without diverticulosis at index colonoscopy, respectively. Of the 50 patients that developed diverticulitis, 21 were complicated and 29 uncomplicated. CONCLUSION: Diverticulosis is a common condition in the population, although most patients will not develop diverticulitis.

Minor impact of anastomotic leakage in anterior resection for rectal cancer on long-term male urinary and sexual function.

PURPOSE: Anastomotic leakage after anterior resection for rectal cancer induces bowel dysfunction, but the influence on urinary and sexual function is largely unknown. This cross-sectional cohort study evaluated long-term effect of anastomotic leakage on urinary and sexual function in male patients. METHODS: Patients operated with anterior resection for rectal cancer in 15 Swedish hospitals 2007-2013 were identified. Anastomotic leakage and other clinical variables were retrieved from the Swedish Colorectal Cancer Registry and medical records. Urinary and sexual dysfunction were evaluated at 4 to 11 years after surgery using the International Prostate Symptom Score, International Index of Erectile Function, and European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire CR29. The effect of anastomotic leakage on average scores of urinary and sexual dysfunction was evaluated as a primary outcome, and the single items permanent urinary catheter and sexual inactivity as secondary outcomes. The association of anastomotic leakage and functional outcomes was analyzed using regression models with adjustment for confounders. RESULTS: After a median follow-up of 84 months (interquartile range: 67-110), 379 out of 864 eligible men were included. Fifty-nine (16%) patients had anastomotic leakage. Urinary incontinence was more common in the leakage group, with an adjusted mean score difference measured by EORTC QLQ ColoRectal-29 of 8.69 (95% confidence interval: 0.72-16.67). The higher risks of urinary frequency, permanent urinary catheter, and sexual inactivity did not reach significance. CONCLUSION: Anastomotic leakage after anterior resection had a minor negative impact on urinary and sexual function in men.

Postoperative morbidity following Hartmann's procedure in comparison to anterior resection and abdominoperineal resection for rectal cancer-a population-based study.

AIM: There is ongoing controversy regarding the extent to which Hartmann's procedure (HP) should be used in rectal cancer treatment. This study was designed to investigate 30-day postoperative morbidity and mortality following HP, anterior resection (AR) and abdominoperineal resection (APR) for rectal cancer using a national registry. METHODS: All patients operated for rectal cancer, tumour height 5-15 cm, between the years 2010 and 2017, were identified through the Swedish colorectal cancer registry. RESULTS: A total of 8476 patients were included: 1210 (14%) undergoing HP, 5406 (64%) AR and 1860 (22%) APR. HP was associated with an increased risk of intra-abdominal infection (OR 1.7, CI 1.26-2.28, P = 0.0004) compared to AR and APR, while APR was related to an increased risk of overall complications (OR 1.18, CI 1.01-1.40, P = 0.040). No significant difference was observed in the rate of reoperations and readmissions between HP, AR and APR, and type of surgical procedure was not a risk factor for 30-day mortality. Findings from a subgroup analysis of patients with a tumour 5-7 cm from the anal verge revealed that HP was not associated with increased risk for complications or 30-day mortality. CONCLUSIONS: For patients where AR is not appropriate HP is a valid alternative with a favourable outcome. APR was associated with the highest overall 30-day complication rate.

Postoperative complications and emergency surgeries in colorectal cancer patients <50 years-a national cohort study.

AIM: The incidence of colorectal cancer (CRC) in Sweden is increasing in individuals <50 years. This study aimed to examine differences in postoperative 30-day complications and rate of emergency surgeries in CRC patients <50 years at diagnosis compared to older age groups since population-based research on this topic is scarce. METHOD: This population-based study included data from the Swedish Colorectal Cancer Registry for patients undergoing CRC resection between 2010 and 2018. Bivariate analysis and logistic regression were used to analyse the relationship between age groups (<50, 50-79 and ≥80 years) and probability of postoperative 30-day complications adjusted for gender, tumour localization, neoadjuvant (chemo)radiotherapy and American Society of Anesthesiologists score. RESULTS: In total 33 320 patients were included. Patients <50 years had a lower American Society of Anesthesiologists score, more advanced tumours and received more neoadjuvant treatment. Emergency surgeries were less common in the youngest age group (P < 0.001) as well as overall postoperative 30-day complications: ORadj 0.84 (95% CI 0.74-0.96) compared to those ≥80 years. Surgical complications were more common in age groups <50 and 50-79 years (16.5% and 16.9% respectively) compared to patients ≥80 years (14.1%) (P < 0.001). Anastomotic leakage and intra-abdominal infections were more frequent in patients <50 years (5.7% and 3.5% respectively) compared to age groups 50-79 years (5.1% and 2.8% respectively) and ≥80 years (3.5% and 2.1% respectively) (P < 0.001). Wound infections were more common in the two youngest age groups compared to patients ≥80 years (5.3% vs. 3.7% respectively) (P < 0.001). CONCLUSION: Colorectal cancer patients <50 years and 50-79 years had a higher proportion of surgical complications regarding anastomotic leakage, intra-abdominal infections and wound infections but lower overall postoperative complications. The incidence of surgical emergencies was highest amongst patients ≥80 years. Postoperative diagnostic workup in symptomatic individuals <50 years is warranted.

Hartmann's procedure in rectal cancer surgery is often an intraoperative decision: a retrospective multicenter study.

PURPOSE: This study aimed to investigate patient-related factors predicting the selection of rectal cancer patients to Hartmann's procedure as well as to investigate how often, and on what grounds, anterior resection is intraoperatively changed to Hartmann's procedure. METHODS: Prospectively collected data from the Swedish Colorectal Cancer Registry regarding patients with rectal cancer operated upon from January 1 2007 to June 30 2017 in the county of Skåne were retrospectively reviewed. Data were expanded with further details from medical charts. A univariable analysis was performed to investigate variables associated with unplanned HP and significant variables included in a multivariable logistic regression analysis. RESULTS: Altogether, 1141 patients who underwent Hartmann's procedure (275 patients, 24%), anterior resection (491 patients, 43%), or abdominoperineal resection (375 patients, 33%) were included. Patients undergoing Hartmann's procedure were significantly older and had more frequently comorbidity. The decision to perform Hartmann's procedure was made preoperatively in 209 (76%) patients, most commonly because of a comorbidity (27%) or oncological reasons (25%). Patient preference was noted in 8% of cases. In 64 cases (23%), the decision was made intraoperatively, most often due to anastomotic difficulties (60%) and oncological reasons (22%). Anastomotic difficulties were most often reported due to technical difficulties, a low tumor or neoadjuvant radiotherapy. Male gender was a significant risk factor for undergoing unplanned Hartmann's procedure. CONCLUSIONS: The decision to perform Hartmann's procedure was frequently made intraoperatively. Hartmann's procedure should be considered and discussed preoperatively in old and frail patients, especially in the presence of mid-rectal cancer and/or male gender, since these factors increase the risk of intraoperative anastomotic difficulties.

Circumferential Resection Margin is Associated With Distant Metastasis After Rectal Cancer Surgery: A Nation-wide Population-based Study Cohort.

OBJECTIVE: To evaluate circumferential resection margin (CRM) as a risk factor for distant metastasis (DM) in rectal cancer. SUMMARY OF BACKGROUND DATA: The treatment of rectal cancer has evolved over the last decades. Surgical radicality is considered the most important factor in preventing recurrences including local and distant. CRM ≤1.0 mm is considered to increase recurrence risk. This study explores the risk of DM in relation to exact CRM. METHODS: All patients treated with abdominal resection surgery for rectal cancer between 2005 and 2013 in Sweden were eligible for inclusion in this retrospective study. Primary endpoint was DM. RESULTS: Twelve thousand one hundred forty-six cases were identified. Eight thousand five hundred ninety-three cases were analyzed after exclusion. Seven hundred seventeen (8.6%) patients had CRM ≤1.0mm and 7577 (91.4%) patients had CRM >1.0 mm. DM recurrence rate at 5 years was 42.1% (95% CI 32.5-50.3), 31.5% (95% CI 27.3-35.5), 25.8% (95% Confidence Interval (CI) 16.2-34.4), and 19.5% (95% CI 18.5-19.5) when CRM was 0.0 mm, 0.1 to 1.0 mm, 1.1 to 1.9 mm, and CRM ≥2mm, respectively. Multivariable analysis revealed higher DM risk in CRM 0.0-1.0 mm versus >1.0 mm (hazard ratio 1.30, 95% CI 1.05-1.60; P = 0.015). No significant difference in DM risk in CRM 1.1-1.9 mm versus ≥2.0 mm (hazard ratio 0.66, 95% CI 0.34-1.28; P = 0.224) could be detected. CONCLUSIONS: The risk of DM decreases with increasing CRM. Moreover, CRM ≤1.0 mm is a significant risk factor for DM. Thus, CRM is a dominant factor when discussing risk of DM after rectal cancer surgery.

Negative Prognostic Impact of Tumor Deposits in Rectal Cancer: A National Study Cohort.

OBJECTIVE: To investigate whether tumor deposits (TDs) in rectal cancer are associated with increased recurrence risk and decreased survival. BACKGROUND: Tumor deposits (TDs) are considered a risk factor for recurrence after colon cancer resection, and the presence of TDs prompts adjuvant chemotherapy. The prognostic relevance of TDs in rectal cancer requires further exploration. METHODS: All patients treated with abdominal resection surgery for rectal cancer in Sweden between 2011 and 2014 were eligible for inclusion in this retrospective cohort study based on prospectively collected data from the Swedish Colorectal Cancer Registry. The primary endpoint was local recurrence or distant metastasis. Secondary outcomes were overall and relative survival. RESULTS: Five thousand four hundred fifty-five patients were identified of which 3769 patients were analyzed after exclusion. TDs were found in 404 (10.7%) patients, including 140 (3.7%) patients with N1c-status. In TD-positive patients, local recurrence and distant metastasis rates at 5 years were 6.3% [95% CI 3.8-8.8%] and 38.9% [95% CI, 33.6-43.5%] compared with 2.7% [95% CI, 2.1-3.3%] and 14.3% [95% CI, 13.1-15.5%] in TD-negative patients. In multivariable regression analysis, the risk of local recurrence and distant metastasis were increased; HR 1.86 [95% CI, 1.09-3.19; P =0.024] and 1.87 [95% CI, 1.52-2.31; P =<0.001], respectively. Overall survival at 5 years was 68.8% [95% CI, 64.4-73.4%] in TD-positive patients and 80.7% [95% CI, 79.4-82.1%] in TD-negative patients. pN1c-patients had similar outcomes regarding local recurrence, distant metastasis, and survival as pN1a-b stage patients. TD-positive pN1a-b patients had significantly worse outcomes whereas TDs did not affect outcomes in pN2a-b patients. CONCLUSION: This study suggests that TDs have a negative impact on the prognosis in rectal cancer. Thus, efforts should be made to diagnose TD-positive rectal cancer patients preoperatively.

Laparoscopic lavage for Hinchey III perforated diverticulitis: factors for treatment failure in two randomized clinical trials.

BACKGROUND: The Scandinavian Diverticulitis (SCANDIV) trial and the LOLA arm of the LADIES trial randomized patients with Hinchey III perforated diverticulitis to laparoscopic peritoneal lavage or sigmoid resection. The aim of this analysis was to identify risk factors for treatment failure in patients with Hinchey III perforated diverticulitis. METHODS: This was a post hoc analysis of the SCANDIV trial and LOLA arm. Treatment failure was defined as morbidity requiring general anaesthesia (Clavien-Dindo grade IIIb or higher) within 90 days. Age, sex, BMI, ASA fitness grade, smoking status, previous episodes of diverticulitis, previous abdominal surgery, time to surgery, and surgical competence were all tested in univariable and multivariable logistic regression analyses using an interaction variable. RESULTS: The pooled analysis included 222 patients randomized to laparoscopic lavage and primary resection (116 and 106 patients respectively). Univariable analysis found ASA grade to be associated with advanced morbidity in both groups, and the following factors in the laparoscopic lavage group: smoking, corticosteroid use, and BMI. Significant factors for laparoscopic lavage morbidity in multivariable analysis were smoking (OR 7.05, 95 per cent c.i. 2.07 to 23.98; P = 0.002) and corticosteroid use (OR 6.02, 1.54 to 23.51; P = 0.010). CONCLUSION: Active smoking status and corticosteroid use were risk factors for laparoscopic lavage treatment failure (advanced morbidity) in patients with perforated diverticulitis.

Multisocietal European consensus on the terminology, diagnosis, and management of patients with synchronous colorectal cancer and liver metastases: an E-AHPBA consensus in partnership with ESSO, ESCP, ESGAR, and CIRSE.

BACKGROUND: Contemporary management of patients with synchronous colorectal cancer and liver metastases is complex. The aim of this project was to provide a practical framework for care of patients with synchronous colorectal cancer and liver metastases, with a focus on terminology, diagnosis, and management. METHODS: This project was a multiorganizational, multidisciplinary consensus. The consensus group produced statements which focused on terminology, diagnosis, and management. Statements were refined during an online Delphi process, and those with 70 per cent agreement or above were reviewed at a final meeting. Iterations of the report were shared by electronic mail to arrive at a final agreed document comprising 12 key statements. RESULTS: Synchronous liver metastases are those detected at the time of presentation of the primary tumour. The term 'early metachronous metastases' applies to those absent at presentation but detected within 12 months of diagnosis of the primary tumour, the term 'late metachronous metastases' applies to those detected after 12 months. 'Disappearing metastases' applies to lesions that are no longer detectable on MRI after systemic chemotherapy. Guidance was provided on the recommended composition of tumour boards, and clinical assessment in emergency and elective settings. The consensus focused on treatment pathways, including systemic chemotherapy, synchronous surgery, and the staged approach with either colorectal or liver-directed surgery as first step. Management of pulmonary metastases and the role of minimally invasive surgery was discussed. CONCLUSION: The recommendations of this contemporary consensus provide information of practical value to clinicians managing patients with synchronous colorectal cancer and liver metastases.

Muscle mass and quality as predictors for complications, recurrence and length of hospital stay in acute uncomplicated diverticulitis: a retrospective cohort study.

OBJECTIVES: The aim of this study was to investigate the potential correlation between muscle mass/muscle quality and risk of complications or recurrence in patients presenting with acute uncomplicated diverticulitis. It was also to study if low muscle mass/quality correlated to prolonged hospital stay. MATERIALS AND METHODS: The study population comprised 501 patients admitted to Helsingborg Hospital or Skåne University Hospital between 1 January 2015 and 31 December 2017, who had been diagnosed with acute uncomplicated diverticulitis and undergone computed tomography upon admission. The scans were used to estimate skeletal muscle mass and muscle radiation attenuation (an indicator for muscle quality). Skeletal muscle index was obtained by adjusting skeletal muscle mass to the patients' height. Values of below the fifth percentile of a normal population were considered low. RESULTS: There were no differences between the patients with normal versus those with low skeletal muscle mass, skeletal muscle index or muscle radiation attenuation regarding risk of complications or recurrence of diverticular disease. However, as only 11 patients had complications, no conclusion as to a potential correlation can be made. Low muscle quality correlated to longer hospital stay, also when adjusting for other potential confounders. CONCLUSIONS: Muscle mass/quality do not seem to serve as predictor of risk for recurrent disease in patients with acute uncomplicated diverticulitis. However, low muscle radiation attenuation was associated with prolonged hospital stay. This indicates that muscle quality, assessed by computed tomography scan, might be used in clinical practise to identify patients at risk of longer hospitalisation.

Emergency subtotal colectomy rates in relation to anti-TNF therapy in inflammatory bowel disease patients: comparison of retrospective cohorts.

OBJECTIVES: The introduction of anti-TNF therapy has revolutionized the management of inflammatory bowel disease (IBD). This study aimed to investigate the impact of anti-TNF therapy on emergency subtotal colectomy rates in patients with IBD (ulcerative colitis, Crohn's disease or indeterminate colitis) during two time periods. METHODS: IBD patients treated with emergency subtotal colectomy for acute severe colitis at Skåne University Hospital, Sweden, during two six-year windows were included. The two time-windows represented pre- and introductory (2004-2009) versus post-introductory (2012-2017) anti-TNF therapy usage. The two periods were compared in terms of the proportion of patients who received anti-TNF therapy, rates of emergency subtotal colectomy, and local IBD prevalence numbers. RESULTS: In total 91 patients were included, 42 (2004-2009) and 49 (2012-2017) patients, respectively. The proportion of patients that received anti-TNF therapy prior to admission was increased from 29% (2004-2009) to 63% (2012-2017) (p = .001). Despite this no significant difference was found in the emergency subtotal colectomy rates between the time periods considering the population at risk (IBD patients living in Skåne county); 1.44/1000 person years versus 1.37/1000 person years (p = .83). CONCLUSION: Despite an increased proportion of patients with IBD that received anti-TNF therapy prior to admission, no significant decrease in emergency subtotal colectomy rates was noted. Further research is warranted, and a prospective study design would facilitate a better causal understanding.

Impact of previous diverticulitis on 5-year survival and recurrence rates in patients with colorectal cancer.

BACKGROUND: Diverticulitis and colorectal cancer (CRC) share epidemiological characteristics, but their relationship remains unknown. It is unclear if prognosis following CRC differ for patients with previous diverticulitis compared to those with sporadic cases and patients with inflammatory bowel disease or hereditary syndromes. AIM: The aim was to determine 5-year survival and recurrence after colorectal cancer in patients with previous diverticulitis, inflammatory bowel disease and hereditary colorectal cancer compared to sporadic cases. METHODS: Patients <75 years of age diagnosed with colorectal cancer at Skåne University Hospital Malmö, Sweden, between January 1st 2012 and December 31st 2017 were identified through the Swedish colorectal cancer registry. Data was retrieved from the Swedish colorectal cancer registry and chart review. Five-year survival and recurrence in colorectal cancer patients with previous diverticulitis were compared to sporadic cases, inflammatory bowel disease associated and hereditary colorectal cancer. RESULTS: The study cohort comprised 1052 patients, 28 (2.7%) with previous diverticulitis, 26 (2.5%) IBD, 4 (1.3%) hereditary syndromes and 984 (93.5%) sporadic cases. Patients with a history of acute complicated diverticulitis had a significantly lower 5-year survival rate (61.1%) and higher recurrence rate (38.9%) compared to sporadic cases (87.5% and 18.8% respectively). CONCLUSION: Patients with acute complicated diverticulitis had worse 5-year prognosis compared to sporadic cases. The results emphasize the importance of early detection of colorectal cancer in patients with acute complicated diverticulitis.

Adverse impact of tumor deposits in lymph node negative rectal cancer - a national cohort study.

PURPOSE: This study aimed to investigate the prognostic effect of tumor deposits (TDs) in lymph node negative rectal cancer. METHODS: Patients who had undergone surgery for rectal cancer with curative intention between 2011 and 2014 were extracted from the Swedish Colorectal Cancer Registry. Patients with positive lymph nodes, undisclosed TD status, stage IV disease, non-radical resections, or any outcome (local recurrence (LR), distant metastasis (DM) or mortality) within 90 days after surgery were excluded. TDs status was based on histopathological reports. Cox-regression analyses were used to examine the prognostic impact of TDs on LR, DM, and overall survival (OS) in lymph node-negative rectal cancer. RESULTS: A total of 5455 patients were assessed for inclusion of which 2667 patients were analyzed, with TDs present in 158 patients. TD-positive patients had a lower 5-year DM-free survival (72.8%, p < 0.0001) and 5-year overall survival (75.9%, p = 0.016), but not 5-year LR-free survival (97.6%) compared to TD-negative patients (90.2%, 83.1% and 95.6%, respectively). In multivariable regression analysis, TDs increased the risk of DM [HR 4.06, 95% CI 2.72-6.06, p < 0.001] and reduced the OS [HR 1.83, 95% CI 1.35-2.48, p < 0.001]. For LR, only univariable regression analysis was performed which showed no increased risk of LR [HR 1.88, 95% CI 0.86-4.11, p = 0.11]. CONCLUSION: TDs are a negative predictor of DM and OS in lymph node-negative rectal cancer and could be taken into consideration when planning adjuvant treatment.

Defunctioning stoma in anterior resection for rectal cancer does not impact anastomotic leakage: a national population-based cohort study.

BACKGROUND: Anterior resection (AR) is considered the gold standard for curative cancer treatment in the middle and upper rectum. The goal of the sphincter-preserving procedure, such as AR, is vulnerable to anastomotic leak (AL) complications. Defunctioning stoma (DS) became the protective measure against AL. Often a defunctioning loop-ileostomy is used, which is associated with substantial morbidity. However, not much is known if the routine use of DS reduces the overall incidence of AL. METHODS: Elective patients subjected to AR in 2007-2009 and 2016-18 were recruited from the Swedish colorectal cancer registry (SCRCR). Patient characteristics, including DS status and occurrence of AL, were analyzed. In addition, independent risk factors for AL were investigated by multivariable regression. RESULTS: The statistical increase of DS from 71.6% in 2007-2009 to 76.7% in 2016-2018 did not impact the incidence of AL (9.2% and 8.2%), respectively. DLI was constructed in more than 35% of high-located tumors ≥ 11 cm from the anal verge. Multivariable analysis showed that male gender, ASA 3-4, BMI > 30 kg/m2, and neoadjuvant therapy were independent risk factors for AL. CONCLUSION: Routine DS did not decrease overall AL after AR. A selective decision algorithm for DS construction is needed to protect from AL and mitigate DS morbidities.

The multi-societal European consensus on the terminology, diagnosis and management of patients with synchronous colorectal cancer and liver metastases: an E-AHPBA consensus in partnership with ESSO, ESCP, ESGAR, and CIRSE.

BACKGROUND: Contemporary management of patients with synchronous colorectal cancer and liver metastases is complex. The aim of this project was to provide a practical framework for care of patients with synchronous colorectal cancer and liver metastases with a focus on terminology, diagnosis and management. METHODS: This project was a multi-organisational, multidisciplinary consensus. The consensus group produced statements which focused on terminology, diagnosis and management. Statements were refined during an online Delphi process and those with 70% agreement or above were reviewed at a final meeting. Iterations of the report were shared by electronic mail to arrive at a final agreed document comprising twelve key statements. RESULTS: Synchronous liver metastases are those detected at the time of presentation of the primary tumour. The term "early metachronous metastases" applies to those absent at presentation but detected within 12 months of diagnosis of the primary tumour with "late metachronous metastases" applied to those detected after 12 months. Disappearing metastases applies to lesions which are no longer detectable on MR scan after systemic chemotherapy. Guidance was provided on the recommended composition of tumour boards and clinical assessment in emergency and elective settings. The consensus focused on treatment pathways including systemic chemotherapy, synchronous surgery and the staged approach with either colorectal or liver-directed surgery as first step. Management of pulmonary metastases and the role of minimally invasive surgery was discussed. CONCLUSIONS: The recommendations of this contemporary consensus provide information of practical value to clinicians managing patients with synchronous colorectal cancer and liver metastases.

High Risk of Low Anterior Resection Syndrome in Long-term Follow-up After Anastomotic Leakage in Anterior Resection for Rectal Cancer.

BACKGROUND: Low anterior resection syndrome is common after sphincter-sparing surgery, but it is unclear to what extent anastomotic leakage after anterior resection contributes to this condition. OBJECTIVE: The aim of this study is to assess the long-term effect of anastomotic leakage on the occurrence of major low anterior resection syndrome. DESIGN: This is a retrospective observational cohort study evaluating low anterior resection syndrome 4 to 11 years after index surgery. After propensity score-matching using the covariates sex, age, tumor stage, comorbidity, neoadjuvant treatment, extent of mesorectal excision, and defunctioning stoma at index surgery, the effect of anastomotic leakage on low anterior resection syndrome was investigated using relative risk and 95% CI. SETTINGS: This multicenter study included patients from 15 Swedish hospitals between 2007 and 2013. PATIENTS: Patients who underwent anterior resection for rectal cancer were included. MAIN OUTCOME MEASURES: Outcome measures included patient-reported major low anterior resection syndrome, obtained via a postal questionnaire that included a question on stoma status. RESULTS: Among 1099 patients, 653 (59.4%) responded in at a median of 83.5 (interquartile range 66 to 110) months postoperatively. After excluding patients with residual stoma or incomplete responses, 544 remained; of these, 42 had anastomotic leakage. Patients with anastomotic leakage were more likely to have major low anterior resection syndrome (66.7% [28/42]) than patients without leakage (45.8% [230/502]). After matching, anastomotic leakage was significantly related to major low anterior resection syndrome (relative risk 2.3; 95% CI 1.4-3.9) and the individual symptom of urgency (relative risk 2.1; 95% CI 1.1-4.1). LIMITATIONS: This study was limited by its retrospective observational study design. CONCLUSIONS: In long-term follow-up, major low anterior resection syndrome is common after anterior resection for rectal cancer. Anastomotic leakage appears to increase the risk of major low anterior resection syndrome, with urgency as a major contributing symptom. See Video Abstract at http://links.lww.com/DCR/B868 . ALTO RIESGO DE SNDROME DE RESECCIN ANTERIOR BAJA EN EL SEGUIMIENTO A LARGO PLAZO TRAS FUGA ANASTOMTICA EN RESECCIN ANTERIOR POR CNCER DE RECTO: ANTECEDENTES:El síndrome de resección anterior baja es común después de una cirugía con preservación de esfínter pero no está claro hasta qué punto contribuye a esta condición la fuga anastomótica después de una resección anterior.OBJETIVO:El objetivo de este estudio es evaluar el efecto a largo plazo de la fuga anastomótica sobre la aparición de un síndrome de resección anterior baja mayor.DISEÑO:Se trata de un estudio de cohorte observacional retrospectivo que evalúa el síndrome de resección anterior baja 4-11 años después de la cirugía índice. Después del apareamiento por puntuación de propensión utilizando las covariables sexo, edad, estadio del tumor, comorbilidad, tratamiento neoadyuvante, extensión de la escisión mesorrectal y estoma de derivación en la cirugía índice, se investigó el efecto de la fuga anastomótica en el síndrome de resección anterior baja utilizando el riesgo relativo y intervalos de confianza de 95%.AJUSTES:Este estudio multicéntrico incluyó pacientes de 15 hospitales suecos entre 2007 y 2013.PACIENTES:Se incluyeron pacientes que fueron sometidos a resección anterior por cáncer de recto.PRINCIPALES MEDIDAS DE DESENLACE:Síndrome de resección anterior baja mayor informado por el paciente, obtenido a través de un cuestionario postal que incluye una pregunta sobre el estado de estomas.RESULTADOS:De 1099 pacientes, 653 (59,4%) respondieron una mediana de 83,5 meses después de la operación (rango intercuartílico 66-110).Después de excluir a los pacientes con estoma residual o respuestas incompletas, quedaron 544; de estos, 42 tuvieron fuga anastomótica. Los pacientes con fuga anastomótica tenían síndrome de resección anterior baja mayor en el 66,7% (28/42) en comparación con el 45,8% (230/502) de los pacientes sin fuga. Después del apareamiento, la fuga anastomótica se relacionó significativamente con el síndrome de resección anterior baja mayor (riesgo relativo 2,3; intervalo de confianza del 95%: 1,4-3,9) y con el síntoma individual de urgencia (riesgo relativo 2,1; intervalo de confianza del 95% 1,1-4,1).LIMITACIONES:Este estudio estuvo limitado por su diseño de estudio observacional retrospectivo.CONCLUSIONES:En el seguimiento a largo plazo, el síndrome de resección anterior baja mayor es común después de la resección anterior por cáncer de recto. La fuga anastomótica parece aumentar el riesgo de síndrome de resección anterior baja mayor, siendo la urgencia uno de los principales síntomas contribuyentes. Consulte Video Resumen en http://links.lww.com/DCR/B868 . (Traducción-Dr. Juan Carlos Reyes ).

Perineal wound healing after abdominoperineal resection for rectal cancer: a retrospective cohort study.

PURPOSE: Delayed perineal wound healing is a common complication after abdominoperineal resection (APR) in rectal cancer. The primary aim of this study was to evaluate the number of patients with delayed wound healing after APR. Secondary aims were to identify risk factors, and describe treatment. METHODS: Prospectively collected data from the Swedish Colorectal Cancer Registry (SCRCR) was used for retrospective analysis of APR performed at Skåne University Hospital Malmö between 2013 and 2018. Medical charts were retrospectively reviewed. Delayed healing was defined as non-healed perineal wound 30 days postoperatively. Patients undergoing extralevator APR requiring reconstruction were excluded. Statistical analysis was made using SPSS. Risk factors for impaired wound healing were analyzed using a multivariable model. RESULTS: A total of 162 patients were included, of which 114 underwent standard APR (sAPR) and 48 patients intersphincteric APR (isAPR). In the total population, 69% (111/162) were male, with median age 71 (26-87). The overall healing rate was 52% (85/162); 44% (50/114) in sAPR vs 73% (35/48) in isAPR (P < 0.001). Risk factors for impaired healing after multivariable analysis were BMI > 30 (OR 7.0; CI 95% 1.8-26.2, P = 0.004), reoperation (OR 7.9; CI 95% 1.6-39.8, P = 0.013), neoadjuvant radiotherapy (OR 5.2; CI 95% 1.02-25.1, P = 0.047) and sAPR (OR 2.598; CI 95% 1.05-6.41, P = 0.038). Eight percent (13/162) required an intervention (Clavien-Dindo ≥ 3). CONCLUSION: Delayed perineal wound healing is a frequent complication after APR but the majority could be treated conservatively. Several risk factors were identified. Further studies aiming at interventions reducing delayed perineal wound healing after APR are warranted.

Rectal washout during abdominoperineal resection for rectal cancer has no impact on the oncological outcome.

AIM: Intraoperative rectal washout is performed to eliminate exfoliated intraluminal cancer cells and thereby decrease the risk of local recurrence. Rectal washout in abdominoperineal resection has not been studied. The aim of this study was to assess the oncological outcome after rectal washout in abdominoperineal resection for rectal cancer and to find evidence as to whether rectal washout should be performed or not. METHOD: Data for all patients registered in the Swedish Colorectal Cancer Registry who underwent elective surgery with abdominoperineal resection for rectal cancer (TNM Stages I-III) between 2007 and 2013 were analysed using multivariable analysis. RESULTS: No significant differences were shown between the rectal washout group and the no rectal washout group for local recurrence [10/265 (3.8%) vs. 87/2160 (4.0%), p = 0.84], distant metastasis [51/265 (19.2%) vs. 476/2160 (22.0%), p = 0.29] or overall recurrence [53/265 (20.0%) vs. 505/2160 (23.4%), p = 0.21]. In multivariable analysis, rectal washout did not significantly affect the oncological outcome in terms of local recurrence, distant metastasis, overall recurrence or 5-year overall or relative survival. CONCLUSION: Our results do not support routine rectal washout during abdominoperineal resection in order to improve the oncological outcome.

Accuracy of magnetic resonance imaging staging of tumour and nodal stage in rectal cancer treated by primary surgery: a population-based study.

AIM: The preoperative stage of rectal cancer is an important prognostic factor affecting treatment recommendations. Currently, magnetic resonance imaging (MRI) is used for clinical staging to identify patients who should be recommended for neoadjuvant oncological treatment. The aim of this work was to investigate the accuracy of the preoperative T- and N-stage and also involvement of the mesorectal fascia (MRF) as determined by MRI in a Swedish national cohort. METHOD: Patients who had undergone resectional surgery for rectal cancer without neoadjuvant treatment in Sweden in the period 2013-2017 were identified through the Swedish Colorectal Cancer Registry (n = 2062). The T- and N-stage determined by preoperative MRI were compared with the histopathological results. The MRI-assessed MRF status was compared with the circumferential resection margin. RESULTS: Sensitivity for differentiating T1-2 from T3-4 was 69% and specificity 77%. Sensitivity to detect N1-2 was 42% and specificity 81%. Sensitivity for MRF positivity was 50% and specificity 92%. Agreement analysed by weighted kappa analysis was 0.47 for T-stage [confidence interval (CI) 0.44-0.51], 0.24 for N-stage (CI 0.19-0.24) and 0.20 for MRF status (CI 0.12-0.29). CONCLUSION: In this study, accuracy of the preoperative MRI was lower than expected for rectal cancers. Overstaging might lead to potentially harmful neoadjuvant treatment and understaging can lead to a higher risk of tumour recurrence. The results of this study show that efforts should be made to increase the accuracy of the preoperative evaluation in order to optimize treatment recommendations.